Healthcare Provider Details

I. General information

NPI: 1174835771
Provider Name (Legal Business Name): SARAH A SMITH MHR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463142 STATE ROAD 200
YULEE FL
32097-5554
US

IV. Provider business mailing address

463142 STATE ROAD 200
YULEE FL
32097-5554
US

V. Phone/Fax

Practice location:
  • Phone: 904-225-8280
  • Fax: 904-225-8232
Mailing address:
  • Phone: 904-225-8280
  • Fax: 904-225-8232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1061
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCBHCMS100160
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: